Minerva anestesiologica
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We present a review of the hemodynamic management of septic shock. Although substantial amount of evidence is present in this area, most key decisions on the management of these patients remain dependent on physiological reasoning and on pathophysiological principles rather than randomized controlled trials. During primary (early) resuscitation, restoration of adequate arterial pressure and cardiac output using fluids and vasopressor and/or inotropic drugs is guided by basic hemodynamic monitoring and physical examination in the emergency department. ⋯ No specific hemodynamic treatment strategy, be it medications including fluids, monitoring devices or treatment algorithms has yet been proved to improve outcome. Moreover, there is virtually no data on the optimal management of the resolution phase of septic shock. Despite these gaps in knowledge, the data from observational studies and trials suggests that mortality in septic shock has been generally decreasing during the last decade.
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Minerva anestesiologica · Nov 2015
ReviewComplications of immunosuppressive agents therapy in transplant patients.
Solid organ transplantation remains the gold standard for the treatment of end-stage organ dysfunction and saves thousands of lives. Besides the progress of surgery, advances in understanding transplant physiology, immunology and the development of immunosuppressive drugs lead to improved short- and long-term survival. ⋯ Approximately one third of organ recipients require hospital readmission after transplantation because of a multitude of clinical problems related to immunosuppressive therapy. We review the current knowledge on typical complications associated with immunosuppressants with emphasis on the intensivist's perspective.
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Minerva anestesiologica · Nov 2015
ReviewPeriprocedural management of antithrombotic therapy and open issues in cancer patients.
Perioperative management of patients who are receiving anticoagulant or antiplatelet drugs and require surgical or invasive procedure is a dilemma for clinicians. The discontinuation exposes the patient to an exceedingly high risk of thromboembolism while there is an exceedingly high bleeding risk if antithrombotic therapy is continued, strictly related to the type of surgery. This complex management is based on the assessment of thromboembolic and bleeding risk. In this review we analyze the strategies to optimize the perioperative use of antithrombotic drugs with special attention to new oral anticoagulant drugs, also in cancer patients.
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Minerva anestesiologica · Nov 2015
Review Meta AnalysisCerebral vasospasm after traumatic brain injury: an update.
Post-traumatic vasospasm (PTV) remains a poorly understood entity. Using a systematic review approach, we examined the incidence, mechanisms, risk factors, impact on outcome and potential therapies of PTV. ⋯ Mechanical stretching, inflammation, calcium dysregulation, endotelin, contractile proteins, products of cerebral metabolism and cortical spreading depolarization have been involved in PTV pathophysiology. PTV occurs in up to 30-40% of the patients after severe traumatic brain injury. Usually, PTV starts within the first 3 days following head trauma and may last 5 to 10 days. Young age, low Glasgow Coma Score at admission and subarachnoid hemorrhage have been identified as risk factors of PTV. Suspected on transcranial Doppler, PTV diagnosis is best confirmed by angiography, CT angiography or MR angiography, and perfusion and ischaemic consequences by perfusion CT or MRI. Early PTV is associated with poor outcome. No PTV prevention strategy has proved efficient up to now. Regarding PTV treatment, only nimodipine and intra-arterial papaverine have been studied up to now. Treatment with milrinone has been described in a few cases reports and may represent a new therapeutic option.
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Minerva anestesiologica · Nov 2015
Review Meta AnalysisCerebral vasospasm after traumatic brain injury: an update.
Post-traumatic vasospasm (PTV) remains a poorly understood entity. Using a systematic review approach, we examined the incidence, mechanisms, risk factors, impact on outcome and potential therapies of PTV. ⋯ Mechanical stretching, inflammation, calcium dysregulation, endotelin, contractile proteins, products of cerebral metabolism and cortical spreading depolarization have been involved in PTV pathophysiology. PTV occurs in up to 30-40% of the patients after severe traumatic brain injury. Usually, PTV starts within the first 3 days following head trauma and may last 5 to 10 days. Young age, low Glasgow Coma Score at admission and subarachnoid hemorrhage have been identified as risk factors of PTV. Suspected on transcranial Doppler, PTV diagnosis is best confirmed by angiography, CT angiography or MR angiography, and perfusion and ischaemic consequences by perfusion CT or MRI. Early PTV is associated with poor outcome. No PTV prevention strategy has proved efficient up to now. Regarding PTV treatment, only nimodipine and intra-arterial papaverine have been studied up to now. Treatment with milrinone has been described in a few cases reports and may represent a new therapeutic option.